Jan 29, 2015Full Speed Ahead
The number of athletes having arthroscopic hip surgery continues to increase. The good news is that return to play after the procedure is quick.
By Dr. Mark Lawler & Dr. Daniel Solomon
Mark Lawler, MD, and Daniel Solomon, MD, are orthopedic surgeons at Marin Orthopedics and Sports Medicine in Novato, Calif. They can be reached through the Marin Orthopedics Web site at: www.marinorthopedics.com.
Chase Utley had arthroscopic hip surgery to repair a torn labrum in 2008. Fellow baseball player Alex Rodriguez had the surgery done to fix a torn labrum and impingement the following year. Olympic sprinter Tyson Gay had the procedure in 2010.
And because many hip joint problems, including labrum tears and impingements, can be treated successfully with hip arthroscopy, more athletes have had it since then. While arthroscopy for the knee and shoulder have been around for many years, hip arthroscopy is still relatively new to mainstream orthopedics and not as common. But the procedure is gaining in popularity, especially among athletes, because of the fast recovery time associated with it.
Without the use of arthroscopy, the hip has to be approached through an “open” technique–similar to how a hip replacement is performed. It is significantly more invasive, patients have to stay in the hospital for several days following surgery, and the potential for blood loss and infection are greater. Hip arthroscopy is an outpatient procedure, there is minimal blood loss, and the potential for complications is far less.
Arthroscopy is performed with the use of a camera called an arthroscope. Small incisions or “portals” are utilized to insert the camera and surgical instruments into the injury site. The joint is then distended with water to expand the area and increase visualization. As the surgeon performs the procedure, he or she views what they are doing inside the joint on a television screen in the operating room.
Hip arthroscopy is similar to those techniques used in shoulder and knee arthroscopy. However, the anatomy of the hip joint presents some unique and difficult challenges for the surgeon.
Unlike the knee, there is little room to enter with the arthroscope and maneuver within the joint space. Because the hip is a ball-and-socket joint, manipulating the arthroscope inside the joint is like trying to squeeze it in around a tennis ball sitting in a cup.
In order to increase access to the joint, a special table is used to “distract” the femur. Contrary to popular belief, the joint is not dislocated. Newer, improved instruments are continually being developed to aid the procedure and help with anatomical challenges.
THE INJURIES
Though most intra-articular hip injuries go undiagnosed for quite some time, they are increasingly being recognized more quickly. Loose bodies, labral tears, chondral injuries, and femoroacetabular impingement (FAI) are common hip joint diagnoses treated with arthroscopy. Additionally, synovial pathology, joint infection, and extraarticular problems such as a snapping hip or bursitis can be treated with arthroscopy.
Patients usually undergo hip surgery for a tear of the cartilage or labrum. The labrum is analogous to the meniscus in the knee. It is made of fibrocartilage and acts like a gasket, attaching to the rim of the socket and aiding in stability by acting as a fluid seal for the joint. Injury to the labrum can cause significant pain and disability while chronic tears have been linked to the development of arthritis.
Labral tears can be caused by several mechanisms. For young athletes, most tears result from an acute injury to the hip. Twisting injuries, traumatic falls, and hyperflexion/extension mechanisms are common triggers. Like all joints, as we age and have various stages of developing arthritis, more minor actions can lead to degenerative tears of the labrum.
The key to diagnosing most hip injuries is that the athlete will complain of groin pain. Labral tears can cause a sharp “pinching” type of pain that increases with flexion. Patients have also reported locking, catching, and the feeling of “giving way” or instability. The severity of these symptoms varies from disabling pain that prevents an athlete from performing to an athlete being able to compete, but with decreased performance.
FAI syndrome has been linked to many acute and chronic tears. When a patient has impingement, it means that the femoral head/neck butts up against the socket in flexion. This leads to repetitive “pinching” of the labrum between the femur and socket. The labrum is therefore thought to be more vulnerable to tearing both acutely and over time when impingement is present.
Impingement comes in two different forms. The more common variety, cam impingement, occurs when the head and neck of the femur lose their normal shape, creating a cam at the head/neck junction. This cam hits the labrum during certain hip positions such as abduction and internal rotation, creating a gradual tear. The tear can propagate to the adjacent cartilage and create scuffing, wear, and arthritis of the hip joint.
The other form of FAI, pincer impingement, occurs when the rim of the socket extends out and down such that the femoral neck rubs up against it. This too can create friction and a degenerative tear of the labrum. The signs and symptoms of pincer FAI are similar to cam FAI.
Patients with impingement present with a variety of symptoms. The most common is pain with flexion and internal rotation of the hip. Going up stairs, getting out of a chair or low couch, getting in and out of a car, and twisting or squatting activities usually elicit pain.
Other athletes can have similar presentation, however, their pain only presents during athletic movements required in their sport. High repetitive hip flexion athletes tend to complain of pain in maximum flexion (especially if it involves rotation). Jumping athletes report pain both during takeoff and landing. And athletes who play sports involving intensive trunk/hip rotation say that they have pain on their “finishing” side.
DIAGNOSIS
Most hip pathology can be determined by taking the patient’s history and a corresponding physical examination. During the exam, range of motion testing of the joint with comparison to the opposite side is critical. Log roll and Figure-4 tests should also be performed and compared to the unaffected side. Evaluation of extraarticular pathology should be undertaken as well, including a thorough evaluation of the lumbar spine and surrounding nerves. It is well known that lumbar spinal pathology can refer pain to the hip and thigh region.
Radiographic data is also imperative to evaluate the injury. Simple or “plain” x-rays are the first step. They reveal information about the boney structures and architecture. Fractures, dislocations, arthritis, prior injuries, and FAI can all be assessed using x-ray.
Radiographs can also determine arthritis, which, if severe, would contraindicate hip arthroscopy. Additionally, radiographs can show prominence of the femoral neck described as a cam lesion or may suggest loose bodies in the joint. If further information is needed, an MRI with or without dye or contrast can be used.
Sometimes it is difficult to decipher the true area of pathology. Is it hip or back? In the hip joint or outside the hip joint? This is where diagnostic/therapeutic steroid injections can provide needed clarification.
The hip joint and spine are deep structures and difficult to localize for an injection. But using a real-time x-ray, fluoroscope, or ultrasound can increase proper placement and accuracy. This procedure involves placing a needle into the hip joint or the spine, verifying placement/location with x-ray, fluoroscope, or ultrasound, and injecting a local anesthetic and steroid.
If the patient’s pain decreases, either temporarily (from the anesthetic) or long term (from the steroid), the area of pathology is confirmed and treated. If the patient doesn’t get pain relief, then the diagnosis is questioned and other areas are explored.
We prefer ultrasound or fluoroscopic-guided joint injection with local anesthetic and corticosteroid for both diagnostic and therapeutic benefits. If a patient gets good relief, but it doesn’t last beyond a few weeks or months, we choose to get an MRI of the hip joint. MR arthrogram utilizes a pre-MRI injection of contrast material into the joint and may help discover any labral tearing that wasn’t previously detected.
SURGERY
When ultrasound and/or fluoroscopic-guided joint injection doesn’t provide long-term relief, arthroscopic surgery is the patient’s next option. The good news is that it is usually performed on an outpatient basis, which means the patient can go home the same day of the surgery. The procedure takes anywhere from 30 minutes to two hours, depending on the complexity of the injury.
The surgery can be performed with the patient supine or lateral based on the surgeon’s preference. Either way, the set-up should allow the hip to be flexed, as this will open the peripheral compartment. Because the hip joint must be distracted, the patient is placed under general anesthesia.
At the outset, the surgeon usually makes three portals: One for the arthroscope and two “working” portals for tools. Once the damage is identified with the arthroscope, the appropriate corrective procedure is performed. The steps may include:
– Debridement of a torn labrum – Repair of a torn labrum, which involves reattaching the labrum to the socket with anchors and sutures – Removal of a torn labrum – Debridement of chondral lesions – Microfracture, which involves drilling holes into exposed areas of bone to stimulate bleeding in order to fill the defect with scar cartilage – Removal of excessive bone on the femoral neck for cam FAI or socket for pincer FAI.
As with any surgical procedure, complications can occur during arthroscopic surgery. Proper visualization is the key to a successful surgery, therefore, fluoroscopic imaging is utilized to ensure proper initial placement of the arthroscope into the joint.
The surgeon must be careful when inserting tools into the joint, as the limited space increases the risk of iatrogenic damage to the cartilage surface and labrum. Specially designed arthroscopic hip instruments will enhance the surgeon’s ability to access the joint and treat pathology encountered.
The surgeon must also be aware that too much or prolonged traction can lead to nerve damage. Additionally, fluid can extravasate, especially during arthroscopy of the peripheral compartment.
REHAB & RETURN TO ACTIVITY
All surgeries have general post-op principles, such as avoiding joint inflammation via early excessive flexion and abduction. Passive range of motion can be started immediately, with progression to full range of motion at two weeks. Gentle isometrics can be initiated within the first few days. And active range of motion can begin at two weeks and increase as tolerated.
Too aggressive or too much activity within the first six weeks after hip arthroscopy can lead to flares of pain, synovitis, and stiffness. We recommend crutches for a few weeks with gentle range of motion exercises, and beginning very easy exercise on a stationary bike after two weeks. If pain-free, the patient can progress to pool exercises, stretching, and core work. Most athletes can return to play within 12 weeks of a “simple” hip arthroscopy. (See “Rehab Timetable” for more.)
If the procedure is more complex, such as a labral repair with debridement of FAI or microfracture, the recovery will be slower. Protected weight bearing for up to six weeks post-op is necessary after microfracture. Labral repair or treatment of FAI requires protected partial weight bearing for the first two to four weeks.
To view references for this article, go to: www.Training-Conditioning.com/references.
Sidebar: REHAB TIME TABLE
Post-operative rehabilitation guidelines are as important as the surgery itself. Without proper restrictions and progression, recovery will be prolonged and less-than-optimal outcomes will result.
The goals of the patient should be clearly established ahead of time and continually reviewed (and possibly altered) throughout the rehab process. Most patients want to return to an athletic lifestyle as soon as possible, but unrealistic goals should be identified early. Elite athletes often need to be “slowed down” as they tend to try to progress too rapidly, which can actually inhibit their progress.
The following is a general outline for rehabilitation following arthroscopic hip surgery. It may need to be accelerated or decelerated based on an individual basis.
Initial Phase: Days one through 10 The goals during this phase are to protect repaired tissue, diminish pain and inflammation, slowly increase range of motion (ROM), and prevent muscle atrophy. Swelling and pain are controlled with the use of ice, non-steroidal anti-inflammatory drugs (NSAIDs), and pain medicine as needed.
– Weight bearing as tolerated, with crutches as needed (for patients who had microfracture, partial weight bearing should continue for four to six weeks) – Isometrics for quadriceps, gluteals, hamstrings, adductors, and abductors – Active assisted ROM work (do not push through hip flexor pain) – No hip extension in prone position – Gentle straight plane distraction techniques are okay – Closed chain bridging, weight shifts, and balance drills – Stationary bike with little to no resistance for 20 minutes at a time – Avoid hip flexor tendnitis (very common).
Intermediate Phase: Day 11 through week three The goals during this phase are to slowly regain and improve strength, restore normal joint kinematics, introduce core strength and stability, and normalize gait.
– Increase ROM with gradual sustained stretches, as pain permits (not forced) – Begin slow, progressive resistive exercises – Closed chain single-leg bridging – Open chain with slow resistance (pulley or Thera-band) in flexion, extension, adduction, abduction, and hamstring curls as tolerated – Stationary bike as tolerated – Pool exercise (as long as incisions are healed) – AlterG machine if available – Proprioceptive/balance work – Avoid hip flexor tendonitis.
Advanced Phase: Weeks four through six The goals during this phase are to increase functional strength, core strength and stability, and endurance.
– Continue flexibility exercises – Progressively increase resistive and functional strengthening – Closed chain exercises as tolerated – Avoid hip flexor tendonitis and joint inflammation – No regular treadmill/elliptical use.
Return-to-Sport Phase: Weeks six through 12 The goals during this phase are to promote advanced strengthening and increase control and strength during sport specific activities. For most of the phase, patients should focus on restoration of muscular strength and endurance, cardiovascular endurance, and neuromuscular control. Toward the end of the phase, they should be able to return to competition.
– Elliptical trainer – Treadmill walking with progression to jogging – Sport specific/functional movements initiated – Gradual return to sport as goals are met – Demonstration of dynamic neuromuscular control during multi-plane activities without deficits means the athlete is ready to return to play.
